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ISSN: 2320-5407 Int. J. Adv. Res.

5(2), 582-587

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/3188


DOI URL: http://dx.doi.org/10.21474/IJAR01/3188

RESEARCH ARTICLE
ACHILLES TENDON INJURIES AND REPAIR: AN OVERVIEW.

Mohammed Ali Alorayyidh, Wail Akel Alkhaldi, Naif Ahmed Almutairi, Emadmobara kallehyani, Abdullah
Mohammed Alrubaie and Hameed Mohammed A Alshehri.
....
Manuscript Info Abstract
.
Manuscript History The Achilles tendon (AT) is the strongest and thickest tendon in the
body. It serves a fundamental function of linking the soleus and
Received: 18 December 2016 gastrocnemius muscles to the calcaneus bone to enable plantar flexion
Final Accepted: 12 January 2017 about the ankle joint.We aimed by this recent study to overview the
Published: February 2017
Achilles tendon injuries in different aspects, we intended to examine
the causes and risk factors and diagnosis of this condition, However the
main purpose of this study was to evaluate the treatment repair
approaches to Achilles tendon injuries. Computerized search of the
literature in the MEDLINE, CINAHL, and EMBASE databases was
conducted December, 2016. The MESH search terms for MEDLINE
are: Achilles tendon AND tendon injuries OR tendinopathy
Combined with treatment OR repair, with limits for English language
and humans.Safe tendon repair work fixation is necessary to avoid
gapping and permit a sped up rehab. Selection of the stitch material and
knotting method is likewise important to prevent tendon repair
separation.

Copy Right, IJAR, 2017,. All rights reserved.


....
Introduction:-
The Achilles tendon (AT) is the strongest and thickest tendon in the body. It serves a fundamental function of
linking the soleus and gastrocnemius muscles to the calcaneus bone to enable plantar flexion about the ankle joint.
By virtue of its biomechanical homes, the AT affects the capability of numerous human motions (1). An Achilles
tendon injury results from a stretch, tear, or inflammation to the tendon connecting the calf muscle to the back of the
heel (1). These injuries can be painful and so abrupt that they have actually been understood to reduce charging
expert football players in shocking style (1,2). The most typical cause of Achilles tendon tears is a problem called
tendinitis, a degenerative condition brought on by aging or overuse. When a tendon is weakened, trauma can cause it
to burst (1,2). Achilles tendon injuries are common in middle-aged who may not exercise regularly or take time to
stretch effectively prior to an activity (3).

Biopsies recovered at surgery have demonstrated degenerative changes in the majority of ruptured Achilles tendons
(4)
, suggesting that Achilles tendon ruptures could be defined as intense injury of chronically degenerated tendons.
Rotator cuff disorders are the most common reasons for shoulder disability and are very common in the aging
population (5). Full-thickness rotator cuff tears exist in around 13% of people in their 50s (6), 25% of people in their
60s and 50% of individuals in their 80s(5). The etiology of rotator cuff tearing is likely and multifactorial a mix of
age-related degenerative modifications (7)and micro/macrotrauma. Age, smoking cigarettes, family, and
hypercholesterolemia history have actually been revealed to incline individuals to rotator cuff tearing (5). Several

Corresponding Author:- Mohammed Ali Alorayyidh. 582


ISSN: 2320-5407 Int. J. Adv. Res. 5(2), 582-587

treatment and repairs options for Achilles tendon injuries, however in cases of postponed medical diagnosis the
likely success of conservative management may be restricted by an absence of consistency of the tendon ends due to
scarring and retraction. Surgical repair work is promoted (8). Cases of chronic rupture of the tendoachilles by their
very nature will not react to conservative treatment and for that reason will require repair making use of graft (9).

Objectives:-
We aimed by this recent study to overview the Achilles tendon injuries in different aspects, we intended to examine
the causes and risk factors and diagnosis of this condition, However the main purpose of this study was to evaluate
the treatment repair approaches to Achilles tendon injuries.

Methodology:-
Computerized search of the literature in the MEDLINE, CINAHL, and EMBASE databases was conducted
December, 2016. The MESH search terms for MEDLINE are: Achilles tendon AND tendon
injuries OR tendinopathy Combined with treatment OR repair, with limits for English language and humans. the
reference lists of all selected publications were inspected to obtain pertinent publications that were not identified in
the electronic search. The gray literature, that included publications, posters, abstracts, and conference proceedings,
was likewise hand browsed. Full-text short articles were retrieved if the abstract offered inadequate details to
develop eligibility or if the short article passed the very first eligibility screening.

Results:-
Clinical presentation of tendon injured patients:-
The patient usually presents with pain, failure to weight bear and a clear popping feeling or sound after an episode of
activity during which they sustain a forced dorsiflexion of the ankle. The injury can also be sustained throughout
eccentric contraction. The patient frequently describes the sensation of being kicked, shot or perhaps bitten on the
back of the heel(10,11).Intense Achilles tendon rupture can readily be discovered on health examination.
Plantarflexion of the foot is naturally weak (11). The Achilles tendon is best analyzed with the patient kneeling and
the feet hanging over the edge of the chair. In this position soft tissues hang off the Achilles tendon like a tent ridge
pole and problems can be readily visualised (Figure 1)(10). There is regularly a visible problem in the Achilles
tendon. This is accompanied by swelling due to peritendinoushaemotoma.

The flaw in the Achilles tendon is typically palpable with a level of sensitivity of 0.71 and specificity of 0.89.
Maffulli compared the sensitivity and uniqueness of the principal medical tests developed to identify Achilles
tendon rupture (12). Particular tests consist of Simmonds or Thompsons' test with sensitivity of 0.98 and uniqueness
of 0.93. Lesser recognized are the O'Brien and Copeland tests both with a sensitivity of 0.8. Early reports suggest
that approximately 20% of Achilles tendon injuries can be missed by medical assessment alone (13).

Figure 1:- View of the right and left Achilles tendon with the patient prone. The left is ruptured. The right Achilles
tendon is well defined and soft tissues hang off it like a tent. The suspension of the soft tissues off the Achilles
tendon is not visible on the left side as the tendon is ruptured. (10)

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Diagnosis of an Achilles tendon injury:-


The accurate diagnosis of anAchilles tendon injury, such as Achilles tendinopathy and, to a lesser degree, Achilles
tendon tear, is not always clear and uncomplicated (14,15,16) The differential medical diagnosis of an Achilles tendon
injury consists of but is not restricted to retrocalcaneal bursitis, ostrigonum, tarsal tunnel syndrome, posterior tibialis
tendon rupture, arthritic conditions, plantar fasciitis, and stress fracture (16).

Diagnostic ultrasound and magnetic resonance imaging (MRI) have actually traditionally been considered the
requirement reference requirements to identify Achilles tendon injuries (14,15,16). However, this screening can be
pricey and might not lead to accurate medical diagnosis (17,18,19). Because of restricted proof assistance, the American
Academy of Orthopaedic Surgeons' scientific practice guidelines recommendation was undetermined relating to the
regular use of MRI for identifying intense Achilles tendon tears (19,20,21).

Treatment (repair)of Achilles tendon injuries:-


Although non-operative treatment can give satisfying results, current research studies have recommended that
operative repair work of the AT may have advantages such as reduced ankle stiffness and calf atrophy, fewer
cutaneous adhesions, and lower risk of trombophlebitis. For the purpose of this evaluation, it is important to
highlight that non-operative treatment cannot avoid tendon lengthening (22). In a meta-analysis conducted by Khan et
al., including 12 randomized control trials and 800 patients, open surgery was related to lower risk of re-rupture than
non-operative treatment however higher risk of other issues, particularly wound problems (23). Surgical treatment
appears to be the technique of option for youths, professional athletes, and delayed ruptures. There is no single,
evenly accepted surgical method, and the choices include open repair, with or without enhancement, and
percutaneous techniques. Minimally invasive and percutaneous techniques have actually been pointed out as valid
healing options for AT ruptures. Khan et al. found that percutaneous surgical treatment was related to lower risk of
complications than open surgery (23). That strategy does not permit the surgeon to imagine the ruptured tendon ends
and accomplish suitable tendon tensioning (24). In addition, imaging research studies have reported that 100 percent
of AT repaired by percutaneous strategy showed residual gap on MRI at 4 weeks postoperative (26). New minimally
invasive methods for AT repair may permit direct visualization of the two ends and have actually been reported
satisfactory clinical results (24).

Surgical Factors Influencing Tendon Tension Repair:-


Secure soft-tissue fixation is essential to numerous clinical applications, from direct tendon repair to tendon transfers
to ligament and tendon reconstructions. It allows for early rehabilitation prior to biological recovery, which is vital
to numerous procedures. Due to the fact that elongation of the graft might be associated with functional construct
failure (26), minimizing elongation of the sutured tendon construct is a vital element of soft tissue fixation.

Biomechanical characteristics of the tendon repair depend mainly on three factors: the quality of the tissue, the
strength of the knot, and the strength of the stitch material itself.The quality of the tissue impacts the "coefficient of
friction," which is the holding capacity of the suture within the tendon. This is an important idea due to the fact that
the failure of the tendon repair work usually occurs due to pull-out of the suture material within the tendon; knot
failing was also observed, while suture damage is unusual (27). Suggestions to reduce tendon extending throughout
Achilles tendon repair are summed up in (Table 1) (28).

Table 1:- Summary of recommendations to reduce tendon lengthening during Achilles tendon repair (28)
1. Free proximal and distal adhesions
2. Use large caliber ( #2) non-absorbable braided suture materials (i.e. polyblend)
3. Use locking suture techniques (i.e. Krackow)
4. Sutures should be place at approximately 2.5 cm from the rupture site
5. Knots should be tied away from the rupture site (i.e. gift-box technique)
6. Epitendinous suture augmentation is recommended

Suture Technique to better influence the tendon healing:-


There are a variety of stitch methods described for grasping and holding soft tissues. When repairing tendons, the
Kessler and Bunnel stitches are well-known for their holding power and are frequently used. In 1986, Krackow et al.
(29)
described a new locking stitch for fixing tendons and ligaments. The traditional Krackow stitch includes three or
more locking loops put along each side of the tendon. Watson et al. (30)demonstrated that the Krackow locking repair
is stronger than Bunnel and Kessler strategy, developing that the Krackow technique is the benchmark

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biomechanically. Extra studies confirmed the exceptional pull-out strength of locking loop methods. McKeon et al.
(31)
found that load to failure is significantly increased by including a 2nd interlocking Krackow stitch positioned 90
to the first. They likewise reported that including more than 2 locking loops did not increase load to failure or
regularly alter elongation. Using only 2 locking loops not only conserves important operative time however also
avoids potential necrosis and injury of the tendon restricted by the loops of the stitch. Extra unnecessary stitch loops
will add more links in the chain, more nonlinear sutures, and maybe increase the risk of extending through slippage.

The site where the knot is tied is also of value when thinking about tension restoration. When the knot is connected
away from the rupture site, 2 different research studies have reported higher repair work strength. Jaakkola et al.
(32)
discovered that the triple bundle is almost three-fold stronger in tension that the Krackow locking loop; this
distinction is generally due to the increased number of strands crossing the rupture site. Another consider this
difference is that the knot was tied far from the rupture site in the triple bundle method, whereas in the Krackow
strategy, the knot is connected at the rupture site. Having the knot at the rupture site might establish a tension riser
on the stitch at the rupture site, and subsequent stress on the suture might lead to early failure at the knot. More
recently, Labib et al. (33) tested a modification of the Krackow technique in which the knots of the stitch were tied
over the cross-limb of the counter stitch (" gift-box" method) (Figure 2) and discovered that the load to failure
increases more than two-fold. The authors thought about that the "gift-box" method is a simple a relatively fast
method without constricting additional tissue during the repair work as reported in the "triple package strategy." (28)

Figure 2:- The Gift-box technique for Achilles tendon repair. Sutures are tied away from the rupture site
(arrows).(28)

Conclusion:-
Achilles tendon rupture is a serious injury for which the best treatment is still questionable. The surgeon needs to
examine a patient's practical requirements thoroughly and treatment need to attempt an optimum restoration of
tendon length, tightness, and tension. For that reason, in attempting to avoid excessive elongation of the tendon,
which is related to a poor clinical outcome, there is consensus that personnel treatment is the preferred healing
alternative for most of patients, specifically young athletes. Safe tendon repair work fixation is necessary to avoid
gapping and permit a sped up rehab. Selection of the stitch material and knotting method is likewise important to
prevent tendon repair separation.

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